Diabetes is a chronic disease of impaired glucose intolerance caused by absolute or relative insulin deficiency.

June 2015

Diabetes is a chronic disease of impaired glucose intolerance caused by absolute or relative insulin deficiency.

Types of Diabetes Type 1 Type 2 Gestational

Diabetes and Pregnancy 0.3% of pregnancies involve women with preexisting diabetes Gestational diabetes occurs in 1-14% of pregnant women. Gestational diabetes is glucose intolerance of variable severity, with onset or first recognition during the current pregnancy

Normal Metabolic Changes in Pregnancy Fasting hypoglycemia (55-65 mg/dl) Postprandial hyperglycemia (enhances delivery of glucose to fetus and promotes fetal growth) Insulin resistance Hyperinsulinemia

Diabetes & Pregnancy Glucose and ketones cross the placenta Insulin does not cross the placenta Ketones may be dangerous to the fetal nervous system and/or may signal maternal DKA

Gestational Diabetes

Gestational Diabetes Elevated glucoses during pregnancy that usually return to normal after delivery Caused by the placental hormone (Human Placental Lactogen) working against maternal insulin

GDM Risk Factors Over age 25 Family history of diabetes Overweight Personal history of gestational diabetes Previous large birthweight baby (>9#) or stillbirth PCOS African American, Hispanic, Asian or Native American

Diagnosis of Gestational Diabetes Risk assessment at first prenatal visit Screen in first trimester or at first prenatal visit if high risk: Personal history of GDM Marked obesity Glycosuria Strong family history of DM Previous large baby (>9#) Prior stillbirth If first trimester result is normal, rescreen at 24-28 weeks

Diagnosis of Gestational Diabetes Screen avg risk women at 24-28 weeks with 1-hour 50-gram GTT (older guidelines) ADA no glucose testing if low risk < 25 years old Normal weight before pregnancy Not in high risk ethnic group No family history of DM in first-degree relatives No history of abnormal GTT No history of poor OB outcome We recommend screening EVERYONE

Diagnosis of Gestational Diabetes If 1-hour GTT is > 140 mg/dl, do 3-hour 100-gram GTT Threshold >140 mg/dl identifies 80% of women with GDM Threshold >130 mg/dl identifies 90% of women with GDM

Diagnosis of Gestational Diabetes 3-hour GTT diagnostic criteria 2 or more values must be met or exceeded for diagnosis of GDM FBS 95 mg/dl 1-hour 180 mg/dl 2-hour 155 mg/dl 3-hour 140 mg/dl (Carpenter and Coustan)

If 3-hour GTT results reveal only one abnormal value, manage patient with: Meal plan Exercise Management of One Abnormal Value Then retest at 32-34 weeks

Current GDM Diagnostic Criteria Established >40 years ago Chosen to identify women at high risk for development of diabetes after pregnancy Derived from criteria for non-pregnant adults Not designed to identify pregnancies with increased risk for adverse perinatal outcome Not based on research of outcomes for fetus/neonate/child Different standards in U.S. and rest of world Yet. we ve always done it that way, so we continue to use them.

New Recommendations for GDM Diagnosis First prenatal visit Measure FPG, HbA1c or random glucose on high-risk women If results indicate overt diabetes, treat as preexisting diabetes If results not diagnostic for overt diabetes FPG >92 but <126, diagnose as GDM FPG <92, test for GDM at 24-28 weeks with 75-gram OGTT

New GDM Diagnostic Criteria 2-hour GTT Recommended by American Diabetes Association in 2010 Still not approved by ACOG Avera McKennan implemented in 2013 75-gram glucola 1 value met or exceeded to make GDM diagnosis FBS 1-hour 2-hour 92 mg/dl 180 mg/dl 153 mg/dl

Implications of New GDM Diagnostic Criteria More women will be dx with GDM, perhaps 2-3x more With current U.S. guidelines, 5-8% of women dx with GDM In HAPO trial, 16% of women met at least one of dx criteria New criteria reflect risk of perinatal harm, not mother s future risk of DM, so should lead to better neonatal outcomes Cost of screening & care

Treatment Goals for GDM Minimize fetal hyperinsulinemia Minimize maternal and fetal complications Baby <90 th percentile for gestational age

Goals for Glucose Control Gestational Diabetes Fasting 1-hour PP 2-hour PP 60-90 mg/dl < 140 mg/dl <120 mg/dl Fasting glucose >105 mg/dl assoc with increased risk of intrauterine death during last 4-8 weeks gestation

Maternal Complications with GDM Polyhydramnios Preterm labor Infections vaginal, bladder & kidney Increased risk for type 2 diabetes (up to 60%)

Fetal Complications with GDM Macrosomia or IUGR Delayed lung maturation Labor and delivery trauma Hypoglycemia Hyperbilirubinemia Polycythemia Hypocalcemia Stillbirth

Complications for Children of Women with GDM Increased risk of Obesity Glucose intolerance Diabetes All can occur in late adolescence and young adulthood

Gestational Diabetes Education Obtain results of GTT from MD/CNM & review with patient If using 2 step method and 1-hour is significantly elevated, 3-hour may be deferred Consider HbA1c to determine if GDM vs. preexisting DM if 1-hour markedly high

Gestational Diabetes Education VISIT 1 Inform/reassure Baby will not be born with diabetes No increased risk for birth defects Nothing mother did to cause GDM Increased risk for type 2 diabetes later in life Good control is essential for a healthy outcome!

Gestational Diabetes Education VISIT 1 Initial education Explanation of GDM GDM risk factors Fetal complications of hyperglycemia Maternal complications of hyperglycemia Goal glucose range Importance of working with healthcare team to achieve a healthy outcome

Gestational Diabetes Education VISIT 1 Treatment regimen Healthy eating Exercise Glucose monitoring (QID fasting and 1-hour postprandial) Ketone testing (first thing daily) Insulin/oral agent if needed Fetal movement counting (daily)

Nutritional Management of Gestational Diabetes Refer to RD experienced in GDM 3 meals/3 snacks daily HS snack EVERY night Avoid juice and cereal for breakfast Limit sugar intake Focus on healthy nutrition for mom and baby Check urine ketones to assess adequacy of HS snack & total daily carb intake

Gestational Diabetes Education VISIT 2 Review glucoses, ketones and food records Check meter memory Schedule third visit if glucoses not in goal range after changes made in meal plan/exercise Ongoing care plan Weekly contact with Diabetes & Pregnancy Team or MD FP/OB/CNM/Perinatologist visits as directed Return for further education if insulin needed

Medications for Glucose Control Glyburide Stimulates pancreatic insulin secretion Several clinical studies have shown it to be safe and effective during pregnancy Does not cross the placenta Starting dose 2.5 mg daily to BID If insulin sensitive, consider 1.25 mg daily Increase in 2.5 mg increments; max dose = 20 mg daily

Medications for Glucose Control Insulin therapy Tailor regimen to glucose pattern Elevated FBS NPH at HS Elevated post-breakfast AM Humalog/NovoLog Elevated post-noon AM NPH Elevated post-supper PM Humalog/NovoLog All elevated NPH with Humalog/NovoLog BID Instruct on insulin administration and hypoglycemia symptoms and treatment

Pre-Existing Diabetes and Pregnancy

Pre-Pregnancy Counseling Should include all women of childbearing age Begin at the onset of puberty Divide women into two categories Planning pregnancy in next year Desire to delay/prevent pregnancy Unplanned pregnancies occur in 2/3 of women with diabetes

Pre-Pregnancy Counseling Optimal glucose control pre-conception HbA1c normal or < 1% above normal for 3-6 months before conception Obtain lowest HbA1c possible without undue risk of maternal hypoglycemia (ADA) Pre-meal glucoses 70-100 mg/dl 1-hour PP glucoses < 140 mg/dl

Pre-Pregnancy Counseling Education Risk and prevention of congenital anomalies Two- to fivefold increased risk of baby with congenital anomaly Organogenesis complete by 8 weeks gestation Chronic complications can worsen with pregnancy Financial realities Personal commitment and motivation Review all aspects of diabetes self-management Early prenatal care

Treatment Goals for Pre-Existing Diabetes Minimize fetal hyperinsulinemia Prevent congenital anomalies Prompt detection of maternal complications Baby < 90 th percentile for gestational age

Maternal Complications with Preexisting Diabetes: Hypoglycemia Ketoacidosis Infections Polyhydramnios Preterm labor Hypertension Worsening of chronic complications Labor and delivery trauma

Maternal Chronic Complications with Pre-Existing Diabetes: Retinopathy Nephropathy Neuropathy Large vessel disease

Fetal Complications with Pre-Existing Diabetes Spontaneous abortion (30-60%) Related to degree of hyperglycemia at conception Congenital anomalies (6-12%) Cardiac Neural tube Skeletal Hyperbilirubinemia Hypocalcemia Polycythemia

Fetal Complications with Pre-Existing Diabetes Hypoglycemia Hypomagnesemia IUGR Macrosomia RDS Birth injury Stillbirth

Goals for Glucose Control Pre-existing Diabetes & Pregnancy Fasting Premeal 1-hour PP 2-hour PP 60-90 mg/dl 60-105 mg/dl < 140 mg/dl <120 mg/dl Fasting glucose >105 mg/dl assoc with increased risk of intrauterine death during last 4-8 weeks gestation

Pre-Existing Diabetes and Pregnancy Management Physical exam and Lab Blood pressure Dilated retinal exam Cardiovascular exam for cardiac or peripheral vascular disease HbA1c 24-hour urine for total protein and creatinine clearance Thyroid panel if type 1

Insulin for all type 1 and type 2 patients At least BID NPH with Humalog/NovoLog Consider Humalog/NovoLog TID and Levemir at HS for type 1 Levemir is now Pregnancy Category B Lantus is Pregnancy Category C Insulin pump follow closely by endocrinologist or perinatologist Oral agent Glyburide has been used safely and effectively in one study for type 2 DM Pre-Existing Diabetes and Pregnancy Management

Pre-Existing Diabetes and Pregnancy Education VISIT 1 Assess current knowledge, skills and practices Meal plan Exercise Insulin administration Glucose monitoring knowledge Urine ketone testing Hypoglycemia symptoms and treatment (milk is preferred treatment) Sick day management

Pre-Existing Diabetes and Pregnancy Education VISIT 1 Instruct on/review key topics as needed Diabetes and pregnancy Rationale for optimal control Potential maternal and fetal complications of hyperglycemia Glucose monitoring regimen Goal glucose ranges Medication regimen

Pre-Existing Diabetes and Pregnancy Education VISIT 1 Metabolic changes during pregnancy 1 st trimester Morning sickness Decreased or same insulin requirements 2 nd trimester Appetite increases Increased insulin requirements 3 rd trimester Increased insulin requirements until last few weeks

Pre-Existing Diabetes and Pregnancy Education VISIT 2 Review glucoses, ketones and food records Check meter memory Additional education as needed Ongoing care plan Weekly contact with Diabetes & Pregnancy Team or MD Ongoing insulin adjustment may require 2-3 times as much insulin as in non-pregnant state Fetal movement counting daily starting at 28 weeks FP/OB/Perinatologist visits as directed

Pre-Existing Diabetes and Pregnancy Monitoring Glucose testing at least QID FBS and 1-hour or 2-hour PP MD may want pre-prandial tests as well May need 0100-0200 check to assess for nocturnal hypoglycemia Ketone testing with first AM void and if ill

Mom Type 1 x 8 years, induced at 39.0 wks, C/S for failure to progress/descend. Baby boy weighed 9# 0 oz., head 14 ½, chest 14. First BG via meter: 44 mg/dl. To NICU for IV.

Mom Type 1 x 11 years, induction of labor at 39.4 weeks. Vaginal birth, 1 st degree laceration. Baby girl, weight 7# 4 oz. First blood glucose via meter 79 mg/dl.

Standard of Care: Fetal Surveillance

Fetal Surveillance: Ultrasound First trimester 16 to 18 weeks 20 to 22 weeks Serial fetal evaluations Doppler flow studies

Fetal Movement Counting Initiate at ~ 28 wks gestation Fetus sensitive to O2 levels, assoc. w/ limb movement Perform approx. same time each day Record length of time to obtain ten kicks Call PCP if time lengthens considerably or has not obtained 10 kicks in 2 hours

Biophysical Profile (BPP) Initiate @ 28 weeks if insulin requiring, 30-34 weeks if non-insulin requiring Variables Fetal tone, gross body movements, fetal breathing, AFV, NST

Scoring of BPP Scoring 2 points for each variable present, 0 if absent Score 8-10 assoc. w/good fetal outcome x 1 wk If 6, repeat or deliver

Nonstress Test (NST) Initiate @ 32-34 wks if insulin requiring, 36 wks if non-insulin requiring Sooner if other risk factors Interpretation: Reactive: 2 accels of 15x15 in 20 minutes Nonreactive: < 2 accels meeting criteria Reactive: weekly to 36 wks, then 2x wk If nonreactive, consider CST or BPP (-) CST, follow-up. (+) CST, amnio or deliver

Contraction Stress Test (CST) Also Oxytocin Challenge Test (OCT) IV pitocin per protocol until: 3 UC s of moderate intensity in 10 min. UC s last 45-60 seconds Nipple stimulation occasionally used

CST Interpretation Negative - no late decels or significant variables Positive - late decels w/50% or > of UC s Equivocal-suspicious - intermittent late decels or significant variable decels Equivocal-hyperstimulatory - FHR decels w/uc s > than q. 2 min. or > 90 sec. Unsatisfactory - fewer than 3 UC s in 10 minutes or an uninterpretable tracing

Amniocentesis L/S ratio (lecithin/sphingomyelin) PG (phospholipid phosphatidylglycerol) Indicated if induction of labor prior to 38-39 weeks gestation, poor dating, poor control Mature L/S ratio (2.0 or >) associated with 3% risk of RDS Presence of PG associated with RDS

Standard of Care: Intrapartal Management

Intrapartum Management Admission history Overall glucose control --- ask to see log book? Episodes of hypoglycemia, ketoacidosis What levels trigger hypoglycemia, S/S, treatment Vascular complications Fetal surveillance testing - U/S for fetal size, hydramnios? Last food intake, insulin dose

Intrapartum Management Non-Insulin Requiring If testing WNL, can often await spontaneous labor Blood glucose on admit and then as ordered (usually every 4-6 hours). Best practice is to use a hospital glucose meter or Lab glucose for all inpatient clinical decisions If necessary to use patient s personal meter, hospital should have a policy in place to validate the accuracy of the patient s meter

Intrapartum Management Non-Insulin Requiring Clear liquids in labor, IV fluids Fetal monitoring as non-diabetic May augment with pitocin, cytotec, cervidil Monitor for signs of CPD or shoulder dystocia (arrest of dilatation or arrest of descent) Monitor baby closely after birth for BG Jitteriness, irritability, lethargy, poor feedings, hypotonia, apnea, cyanosis, seizures

Intrapartum Management Insulin-Requiring With good control, no complications, reassuring AP testing, delivery can be planned at 39 weeks May need IV infusion w/glucose and an insulin drip Spontaneous labor: manage same as non diabetic Induction of labor: Diet and insulin as usual day before induction Withhold insulin and food day of induction IV with glucose @ ~ 100cc/hr

Intrapartum Management Insulin-Requiring Examples of insulin protocols

Insulin & Glucose Requirements At onset of active labor, insulin and glucose requirements may vary 6-8 grams glucose needed/hour in labor D5 solutions, 20 ml = 1 gm (120-160 ml/hr) D10 solutions, 10 ml = 1 gm (60-80 ml/hr) Glucose goals 70 to 110 mg/dl

Intrapartum Management Insulin-Requiring If glucose > defined threshhold (120), initiate insulin drip 250 ml NS with 250U Humulin Regular insulin Flush tubing with 25 ml insulin solution prior to infusion Begin at 1U/hr (1 ml/hr) per infusion pump or per orders or per protocol/orders to achieve glucose goals If patient is fed, adjust rate per physician order Notify MD/CNM if patient unable to eat or emesis Policy requires 2 RN s check IV insulin dose/rate upon initiation and any rate changes

Insulin-Requiring risk ketoacidosis (DKA) with use of tocolytics and/or steroids Observe closely, dip urine for ketones as ordered, anticipate need for increased insulin Glucose monitoring Unit meter (not patient s meter) Lab glucose if < 60 mg/dl or > 400 mg/dl Latent labor: every 2-4 hours as ordered. Active labor: hourly once insulin drip is initiated Check for urine ketones as ordered

Intrapartum Management Insulin-Requiring C/S Schedule early a.m. Diet and insulin as usual day before Withhold insulin and food day of surgery IV fluids - pre-surgery hydrate with LR to avoid hyperglycemia Regional anesthetic preferred

Maternal Assessments Hypoglycemia (jittery, / fine motor dexterity, slowed responses) Hyperglycemia (polyuria, polydipsia, polyphagia, weakness, vision changes) Continuous fetal monitoring - observe for signs of shoulder dystocia

At Delivery GDM and Type 2: Discontinue insulin infusion Type 1: Adjust or stop per physician order Obtain a maternal serum glucose and cord glucose (physician order)

Newborn Management Monitor for hypoglycemia (jittery, lethargy, poor feeding, irritability, hypotonia, apnea, cyanosis, seizures Symptomatic newborn Check immediately If < 40 transfer to NICU for IV glucose

Newborn Management If initial glucose is <30 mg/dl, draw serum glucose If serum glucose is < 25 mg/dl, IV glucose If 30-40 mg.dl, IV glucose

Newborn Management Continue to feed infant every 2-3 hours Screen glucose prior to each feed unless: 3 consecutive levels > 45 mg/dl; then check every other feed for 12-24 hours If glucose is 30-40 mg/dl, feed and re-check in 1 hour (if monitor reads obtain serum plasma level) If serum plasma level is 0-35 mg/dl contact physician and plan for transfer NICU

Standard of Care: Postpartum Management

Postpartum Management Gestational Diabetes No insulin required Regular diet Blood glucose monitoring If diet controlled, no BG s If insulin required, delivery day & 1st PP day or as ordered

Postpartum Management Pre-Existing Diabetes Insulin requirements drop after delivery, may not need insulin for 24-72 hrs BGM Immediately after delivery & q. 4 hrs When eating, begin a.m. fasting & ac or pc Begin insulin or oral agent when BG levels begin to rise (> 90 mg/dl fasting, >120 mg/dl at 2 hrs postprandial) Diet Healthy eating/constant carb (consult dietitian)

Breastfeeding Calorie intake similar to pregnancy ( intake by 300 to 500 calories/day) Insulin requirements may because of milk production Monitor for signs of hypoglycemia, especially at night most likely within 60 min. of BF may need to adjust snacks may need to evening NPH

Breastfeeding & Oral Agents Glucotrol & Glyburide Not reviewed by AAP A group of 5 mothers who received daily doses of glyburide (5 mg) or glucotrol (immediate-release 5 mg), neither was detectable in milk. Infant plasma glucose levels were normal. Glimepiride (Amaryl) not reviewed by AAP No data available on transfer into human milk. However, rodent studies demonstrated significant transfer and elevated plasma levels in pups. Caution is urged if used in BF humans. Observe for hypoglycemia.

Breastfeeding & Oral Agents Glucophage (Metformin) not reviewed by AAP Study of 7 women taking median dose 1500 mg/dl, the absolute infant dose averaged 0.04 mg/kg/day and the mean relative infant dose was 0.28%. Metformin was present in very low or undetectable concentrations in the plasma of four of the infants studied. No health problems.

Postpartum F.U. for Women w/gdm Healthy diet Exercise S/S hyperglycemia If mom wants to check BGs, goal FBS < 90, 2 hr PP < 120 (testing generally not required) 6 week and annual FBS 2 hour GTT with 75 gram glucose load if planning future pregnancies, otherwise FBS only Fasting < 100 mg/dl = Normal 100-125 = Pre-diabetes > 126 = Diabetes

Postpartum Follow Up for Women with GDM (continued) Predisposition to HTN, obesity and type 2 diabetes (67%) S/S: polydipsia, polyuria, polyphagia, blurred vision, HA, drowsiness, nausea, hyperpnea Risk of GDM with future pregnancies (30-50% reoccurrence) Contraceptive options

GDM: Risk of Developing Type 2 DM If woman does NOT become fit & lean after pregnancy, risk of developing Type 2 DM is ~ 10% each year, cumulative In 5 years, your risk of Type 2 DM is 50% Then, lifetime risk caps at ~ 60% If able to become lean & fit after baby is born, lifetime risk is 25% Coustan, D., Carpenter, M., O Sullivan P., & Carr, S. (1993). Gestational diabetes mellitus. Predictors of subsequent disordered glucose metabolism. American Journal of Obstetrics & Gynecology, 168, 1139-1145.

PP Follow Up: Pre-Existing DM Constant carbohydrate diet or carb:insulin ratio Exercise Routine monitoring of glucoses (FBS/premeal goal 80-120 mg/dl; 2 hour post-prandial < 140 mg/dl) QD if diet controlled (rotating times) BID if taking oral diabetes agent (test before meals & HS) Rotate fasting/pre-supper, next day pre-lunch/hs Wait at least 2 hrs since snack before pre-meal testing Daily BGM if BG s okay after 1 week (rotate times) QID if on insulin

The ENDs! For more information, contact: Avera McKennan Diabetes Center at 605-322-8995

References Kjos, S. (2013) Intrapartum and Postpartum Management of Insulin and Blood Glucose. UpToDate. American Acadamy of Pediatrics, The American College of Obstetricians and Gynecologists (2012). Guidelines for Perinatal Care, Seventh Edition.